Simultaneous common bile duct clearance and laparoscopic cholecystectomy: experience of a one-stage approach

Prophylactic cholecystectomy offers best outcomes following ERCP clearance of common bile duct stones: a meta-analysis

BACKGROUND

Symptomatic calculus biliary disease is common with associated morbidity and occasional mortality, further confounded when there is concomitant common bile duct (CBD) stones. Choledocholithiasis and clearance of the duct reduces recurrent cholangitis, but the question is whether after clearance of the CBD if there is a need to perform a cholecystectomy. This meta-analysis evaluated outcomes in patients undergoing ERCP with or without sphincterotomy to determine if cholecystectomy post-ERCP clearance offers optimal outcomes over a wait-and-see approach.

METHODS

A Prospero registered meta-analysis of the literature using PRISMA guidelines incorporating articles related to ERCP, choledocholithiasis, cholangitis and cholecystectomy was undertaken for papers published between 1st January 1991 and 31st May 2021. Existing research that demonstrates outcomes of ERCP with no cholecystectomy versus ERCP and cholecystectomy was reviewed to determine the related key events, complications and mortality of leaving the gallbladder in situ and removing it. Odds ratios (OR) were calculated using Review Manager Version 5.4 and meta-analyses performed using OR using fixed-effect (or random-effect) models, depending on the heterogeneity of studies.

RESULTS

13 studies (n = 2598), published between 2002 and 2019, were included in this meta-analysis, 6 retrospective, 2 propensity score-matched retrospective studies, 3 prospective studies and 2 randomised control trials from a total of 11 countries. There were 1433 in the no cholecystectomy cohort (55.2%) and 1165 in the prophylactic cholecystectomy (44.8%) cohort. Cholecystectomy resulted in a decreased risk of cholecystitis (OR = 0.15; CI 0.07-0.36; p < 0.0001), cholangitis (OR = 0.51; CI 0.26-1.00; p = 0.05) and mortality (OR = 0.38; CI 0.16-0.9; p = 0.03). In addition, prophylactic cholecystectomy resulted in a significant reduction in biliary events, biliary pain and pancreatitis.

CONCLUSIONS

In patients undergoing CBD clearance, consideration should be given to performing prophylactic cholecystectomy to optimise outcomes.

Common bile duct stones management: A network meta-analysis

BACKGROUND

Timely management is critical for treating symptomatic common bile duct (CBD) stones; however, a single optimal management strategy has yet to be defined in the acute care setting. Consequently, this systematic review and network meta-analysis, comparing one-stage (CBD exploration or intraoperative endoscopic retrograde cholangiopancreatography [ERCP] with simultaneous cholecystectomy) and two-stage (precholecystectomy or postcholecystectomy ERCP) procedures, was undertaken with the main outcomes of interest being postprocedural complications and hospital length of stay (LOS).

METHODS

PubMed, SCOPUS, MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were methodically queried for articles from 2010 to 2021. The search terms were a combination of medical subject headings terms and the subsequent terms: gallstone; common bile duct (stone); choledocholithiasis; cholecystitis; endoscopic retrograde cholangiography/ERCP; common bile duct exploration; intraoperative, preoperative, perioperative, and postoperative endoscopic retrograde cholangiography; stone extraction; and one-stage and two-stage procedure. Studies that compared two procedures or more were included, whereas studies not recording complications (bile leak, hemorrhage, pancreatitis, perforation, intra-abdominal infections, and other infections) or LOS were excluded. A network meta-analysis was conducted to compare the four different approaches for managing CBD stones.

RESULTS

A total of 16 studies (8,644 participants) addressing the LOS and 41 studies (19,756 participants) addressing postprocedural complications were included in the analysis. The one-stage approaches were associated with a decrease in LOS compared with the two-stage approaches. Common bile duct exploration demonstrated a lower overall risk of complications compared with preoperative ERCP, but there were no differences in the overall risk of complications in the remaining comparisons. However, differences in specific postprocedural complications were detected between the four different approaches managing CBD stones.

CONCLUSION

This network meta-analysis suggests that both laparoscopic CBD exploration and intraoperative ERCP have equally good outcomes and provide a preferable single-anesthesia patient pathway with a shorter overall length of hospital stay compared with the two-stage approaches.

LEVEL OF EVIDENCE

Systematic Review/Meta Analysis; Level III.

Intraoperative cholangiography: a stepping stone to streamlining the treatment of choledocholithiasis

BACKGROUND

An estimated 8-15% of patients undergoing cholecystectomy have concomitant common bile duct stones. In this 14-year study, we utilize data of patients at a high-volume tertiary care academic center and compare the clinical outcomes of patients undergoing intraoperative cholangiography (IOC) and endoscopic retrograde pancreatography (ERCP).

METHODS

The charts of 1715 patients in the institutional NSQIP database who underwent cholecystectomy between October 1st, 2005 and September 30th, 2019 were retrospectively reviewed. Patients who underwent cholecystectomy in relation to a malignancy diagnosis or who underwent an ERCP in a different index hospitalization were excluded. Main outcomes included hospital length of stay (LOS), post-operative morbidity, and rate of readmissions.

RESULTS

Of the 1409 patients included in the final analysis, 185 patients underwent ERCP, while 95 patients underwent IOC. Use of IOC compared to preoperative ERCP resulted in a shorter LOS (2.6 vs. 5.3 days, p < 0.001), lower rate of readmission (1.1% vs. 6.5%, p = 0.040), and similar rates of post-operative complications. Mean operative time increased by only 15 min in the IOC compared to the ERCP group (129 vs.114 min, p = 0.047). Additional variables that increased LOS on multivariable logistic regression included age, ASA classification, post-operative complications, and increased number of preoperative tests.

CONCLUSIONS

This study demonstrates that use of IOC during cholecystectomy results in shorter LOS and fewer readmissions compared to ERCP. Future studies comparing these two approaches should focus on patient randomization, a cost-effectiveness analysis, and identifying barriers to implementation of a one-stage approach in the management of suspected choledocholithiasis.

Bile duct clearance and cholecystectomy for choledocholithiasis: Definitive single-stage laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiopancreatography versus staged procedures

BACKGROUND

Clinical equipoise exists regarding optimal sequencing in the definitive management of choledocholithiasis. Our current study compares sequential biliary ductal clearance and cholecystectomy at an interval to simultaneous laparoendoscopic management on index admission in a pragmatic retrospective manner.

METHODS

Records were reviewed for all patients admitted between January 2015 and December 2018 to a Swedish and an Irish university hospital. Both hospitals differ in their practice patterns for definitive management of choledocholithiasis. At the Swedish hospital, patients with choledocholithiasis underwent laparoscopic cholecystectomy with intraoperative rendezvous endoscopic retrograde cholangiopancreatography (ERCP) at index admission (one stage). In contrast, interval day-case laparoscopic cholecystectomy followed index admission ERCP (two stages) at the Irish hospital. Clinical characteristics, postprocedural complications, and inpatient duration were compared between cohorts.

RESULTS

Three hundred fifty-seven patients underwent treatment for choledocholithiasis during the study period, of whom 222 (62.2%) underwent a one-stage procedure in Sweden, while 135 (37.8%) underwent treatment in two stages in Ireland. Patients in both cohorts were closely matched in terms of age, sex, and preoperative serum total bilirubin. Patients in the one-stage group exhibited a greater inflammatory reaction on index admission (peak C-reactive protein, 136 ± 137 vs. 95 ± 102 mg/L; p = 0.024), had higher incidence of comorbidities (age-adjusted Charlson Comorbidity Index, ≥3; 37.8% vs. 20.0%; p = 0.003), and overall were less fit for surgery (American Society of Anesthesiologists, ≥3; 11.7% vs. 3.7%; p < 0.001). Despite this, a significantly shorter mean time to definitive treatment, that is, cholecystectomy (3.1 ± 2.5 vs. 40.3 ± 127 days, p = 0.017), without excess morbidity, was seen in the one-stage compared with the two-stage cohort. Patients in the one-stage cohort experienced shorter mean postprocedure length of stay (3.0 ± 4.7 vs. 5.0 ± 4.6 days, p < 0.001) and total length of hospital stay (6.5 ± 4.6 vs. 9.0 ± 7.3 days, p = 0.002). The only significant difference in postoperative complications between the cohorts was urinary retention, with a higher incidence in the one-stage cohort (19% vs. 1%, p = 0.004).

CONCLUSION

Where appropriate expertise and logistics exist within developing models of acute care surgery worldwide, consideration should be given to index-admission laparoscopic cholecystectomy with intraoperative ERCP for the treatment of choledocholithiasis. Our data suggest that this strategy significantly shortens the time to definitive treatment and decreases total hospital stay without any excess in adverse outcomes.

LEVEL OF EVIDENCE

Therapeutic/Care Management Level IV.

A meta-analysis of the use of intraoperative cholangiography; time to revisit our approach to cholecystectomy?

BACKGROUND

Despite some evidence of improved survival with intraoperative cholangiography during cholecystectomy, debate has raged about its benefit, in part because of its questionable benefit, time, and resources required to complete.

METHODS

An International Prospective Register of Systematic Reviews-registered (ID CRD42018102154) meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed, Scopus, Web of Science, and Cochrane library from 2003 to 2018 was undertaken including search strategy "intraoperative AND cholangiogra* AND cholecystectomy." Articles scoring ≥ 16 for comparative and ≥ 10 for noncomparative using the Methodological Index for Non-Randomized Studies criteria were included. A dichotomous random effects meta-analysis using the Mantel-Haenszel method performed on Review Manager Version 5.3 was carried out.

RESULTS

Of 2,059 articles reviewed, 62 met criteria for final analysis. The mean rate of intraoperative cholangiography was 38.8% (range 1.6%-96.4%).There was greater detection of bile duct stones during cholecystectomy with routine intraoperative cholangiography compared with selective intraoperative cholangiography (odds ratio = 3.28, confidence interval = 2.80-3.86, P value < .001). While bile duct injury during cholecystectomy was less with intraoperative cholangiography (0.39%) than without intraoperative cholangiography (0.43%), it was not statistically significant (odds ratio = 0.88, confidence interval = 0.65-1.19, P value = .41). Readmission following cholecystectomy with intraoperative cholangiography was 3.0% compared to 3.5% without intraoperative cholangiography (odds ratio = 0.91, confidence interval = 0.78-1.06, P value = .23).

CONCLUSION

The use of intraoperative cholangiography still has its place in cholecystectomy based on the detection of choledocholithiasis and the potential reduction of unfavorable outcomes associated with common bile duct stones. This meta-analysis, the first to review intraoperative cholangiography use, identified a marked variation in cholangiography use. Retrospective studies limit the ability to critically define association between intraoperative cholangiography use and bile duct injury.

Patterns of prevalence and contemporary clinical management strategies in complicated acute biliary calculous disease: an ESTES 'snapshot audit' of practice

Background

Acute complications of biliary calculi are common, morbid, and complex to manage. Variability exists in the techniques utilized to treat these conditions at an individual surgeon and unit level.

Aim

To identify, through an international prospective nonrandomized cohort study, the epidemiology and areas of practice variability in management of acute complicated calculous biliary disease (ACCBD) and to correlate them against reported outcomes.

Methods

A preplanned analysis of the European Society of Trauma and Emergency Surgery (ESTES) 2018 Complicated Biliary Calculous Disease audit was performed. Patients undergoing emergency hospital admission with ACCBD between 1 October 2018 and 31 October 2018 were included. All eligible patients with acute complicated biliary calculous disease were recorded contemporaneously using a standardized predetermined protocol and a secure online database and followed-up through to 60 days from their admission.

Endpoints

A two-stage data collection strategy collecting patient demographics, details of operative, endoscopic and radiologic intervention, and outcome metrics. Outcome measures included mortality, surgical morbidity, ICU stay, timing of operative intervention, and length of hospital stay.

Results

Three hundred thirty-eight patients were included, with a mean age of 65 years and 54% were female. Diagnosis at admission were: cholecystitis (45.6%), biliary pancreatitis (21%), choledocholithiasis with and without cholangitis (13.9% and 18%). Index admission cholecystectomy was performed in just 50% of cases, and 28% had an ERCP performed. Morbidity and mortality were low.

Conclusion

This first ESTES snapshot audit, a purely descriptive collaborative study, gives rich ‘real world’ insights into local variability in surgical practice as compared to international guidelines, and how this may impact upon outcomes. These granular data will serve to improve overall patient care as well as being hypothesis generating and inform areas needing future prospective study.

More Is Less: The Advantages of Performing Concurrent Laparoscopic Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography for Pediatric Choledocholithiasis

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) are standard of care for pediatric choledocholithiasis. Patients typically undergo separate procedures during hospitalization. Collaboration between surgical and gastroenterology services led to performance of both procedures concurrently during one anesthetic. We hypothesized that concurrent procedures would reduce costs without increasing complications as compared with separate procedures. Materials and Methods: We evaluated patients admitted to our institution from 2013 to 2018 with choledocholithiasis who underwent both ERCP and LC during the same admission. Fourteen patients underwent both procedures during concurrent anesthetic. Forty-two patients who underwent LC and ERCP under separate anesthetics were randomly selected to perform a 3:1 matched case-control study. Demographic and clinical data were collected, including imaging and laboratory findings, outcomes, and costs. Comparative analysis was completed with Fisher's exact and Mann-Whitney U tests. Results: On presentation, there was no difference in common bile duct size, total bilirubin, or white blood cell count between the concurrent and separate procedure cohorts. Significantly, there was no difference in total length of anesthesia (117.9 ± 40 minutes versus 119.6 ± 52 minutes, P = .747). There were also no differences in complications, emergency department visits, or readmissions. Patients who underwent concurrent procedures had significantly lower total cost of stay ($45,597 ± 11,513 versus $61,008 ± 17,960, P = .006). Conclusions: In pediatric patients with choledocholithiasis, performing LC and ERCP may be performed concurrently during one anesthetic, which decreases costs without increasing in anesthesia time or complications.